diagnosis and management of cholestasis
TRANSCRIPT
Obstetric Management of Fibroids and
Prior MyomectomyMARTHA A. MONSON, MD
JUNE 2, 2017
PROJECT ECHO PREGNANCY CARE
Objectives Review definition of fibroids
Brief overview of treatment of fibroids
Review pathophysiology of fibroids in pregnancy and associated recommendations
Review recommendations for obstetric patients status post myomectomy
We will not review management of fibroids in relation to infertility
Uterine Fibroids (a.k.a. Leiomyomas)
https://en.wikipedia.org/wiki/Uterine_fibroid#/media/File:Leiomyoma.jpg
Benign smooth muscle tumors
Epidemiology of FibroidsPrevalence 1.6-10.7%
Risk factorsIncreased maternal age
African American ethnicity
UPTODATE.COM
Diagnosis Clinical (in office and based on exam and symptomatology prior to pregnancy)
UltrasoundHypoechoic, spherical massDistorts myometrial contourMust be differentiated from focal myometrial
contraction (e.g. may disappear during same exam or follow up scan)
Mass may undergo cystic changes if degenerating (not to be confused with ovarian mass)
Color flow may help delineate blood supply
MRI may be useful to confirm degenerating leiomyomas
http://www.emedmd.com/content/fibroids-pregnancy
Rationale for surgical treatment of fibroids
Treatment of severe symptoms E.g. patient has required multiple transfusions and has failed medical management, rapidly growing
fibroid leading to constipation or urinary retention
Infertility treatment (in reference to fibroids involving the uterine cavity)
Treatment for fibroidsFertility (uterus) sparing treatment – “myomectomy” is most commonLaparoscopic myomectomy
Hysteroscopic myomectomy
Abdominal myomectomy
Uterine Artery Embolization Pregnancy not recommended following uterine artery embolization for fibroid management
Hysterectomy is definitive therapy for patients who have completed childbearing
Laparoscopic Myomectomy
https://en.wikipedia.org/wiki/Uterine_fibroid#/media/File:Myomenukleation1.jpg
Hysteroscopic Myomectomy
http://cdn.fibroidsecondopinion.com/wp-content/uploads/2009/05/myo_resect.jpg
http://simbionix.com/simulators/hyst-mentor/hyst-mentor-library-of-modules/hyst-mentor-myomectomy/
Uterine Artery Embolization
http://www.hopkinsmedicine.org/bloodless_medicine_surgery/case_studies/obstetrics_gynecology.html
Pregnancy effect on fibroids Change in size (most commonly in first trimester) 40% stable, remainder increase or decrease in size by more than 10%
1/3 of fibroids >5cm in pregnancy will increase in size
<10% of fibroids <5cm will increase in size
Degenerative changes Fibroid outgrow their blood supply -> ischemia
Ischemia -> hemorrhagic infarction
Patient symptoms:
localized tenderness over fibroid
low grade fevers,
mild leukocytosis
and/or nausea/vomiting
CREASY ET AL, MATERNAL-FETAL MEDICINE
Fibroid effects on pregnancy
WILLIAMSON, ET AL. 2014
Potential complications related to fibroids:
Labor Dystocia/Labor Complications
Spontaneous Abortion Increased Cesarean Section Risk
Fetal Death Postpartum Hemorrhage
Placental Abruption
Abnormal Placentation
Fetal Malpresentation
Preterm Delivery
Fibroid effects on pregnancy
WILLIAMSON, ET AL. 2014
Potential complications related to fibroids:
Spontaneous Abortion◦ Small increased risk for SAB in women with intramural fibroids compared with controls without fibroids
(20% vs. 13%; OR 1.82 (1.34-2.3)).
◦ No effect from fibroid size but number of fibroids (e.g. no increased risk of SAB with single intramural fibroids)
◦ Inconclusive results for effect of submucosal fibroids on risk for miscarriage rate
Fetal Death◦ Increased risk for fetal death in setting of fetal growth restriction in women with fibroids after
controlling for race, diabetes, hypertension, maternal age and excluding fetal anomalies
(OR 2.1 (1.2-3.6)).
◦ No increased risk for fetal death in appropriately sized fetus
◦ Risk greatest for women with >3 fibroids (OR 2.2 (1.1-4.6)) or fibroids >5cm in size (OR 2.6 (1.5-4.5))
Fibroid effects on pregnancy
WILLIAMSON, ET AL. 2014
Potential complications related to fibroids:
Placental Abruption
◦ Conflicting evidence regarding association between fibroids and abruption.
Abnormal Placentation
◦ Large fibroids (>5cm in size) may confer increased risk for placenta previa or abnormally low placentation
Fibroid effects on pregnancy
WILLIAMSON, ET AL. 2014
Potential complications related to fibroids:
Preterm Delivery◦ Women with fibroids have higher rates of hospital admissions for preterm labor <37 weeks (OR 1.5
(1.3-1.7))◦ Correlated with size of fibroid
Fetal Malpresentation◦ Increased risk for fetal malpresentation in setting of uterine fibroids (OR 1.6-4.0 depending on study)
◦ Higher rates of malpresentation at >37 weeks with fibroids >5cm in size with increasing rates of malpresentation with increasing fibroid size.
Labor Dystocia◦ Patients with fibroids who are eligible for a trial of labor have likelihood of successful SVD similar to
general population without fibroids
Fibroid effects on pregnancy
WILLIAMSON, ET AL. 2014
Potential complications related to fibroids:
Increased Cesarean Section Risk◦ Increased rate of cesarean delivery preceding trial of labor (OR 3.7 (3.5-3.9))
◦ Fetal malpresentation
◦ Placenta previa
◦ Lower uterine segment or cervical fibroid below below presenting fetal part
Postpartum Hemorrhage◦ Increased rate of postpartum hemorrhage in women with fibroids (OR 1.8 (1.4-2.2))
Obstetric management in patients with fibroidsCounsel patient on pregnancy risks in setting of fibroids
Routine OB labs and 18-20 week US
Document placental location and size/number of fibroids
Iron supplementation if patient history of anemia due to fibroids preceding pregnancy
Obstetric management in patients with fibroidsConsider repeat ultrasound(s) in pregnancy if large (>5cm) fibroid present
Follow up on placental location if abnormally low (e.g. low lying or previa)
Follow growth of lower uterine segment fibroid and relationship to fetal presenting part
May need MFM consultation/expert opinion if concern that SVD may not be feasible
May need to counsel patient that if Cesarean Delivery is required, a non-low transverse hysterotomy may be indicated
Follow up fetal growth (particularly if fundal height is distorted due to size/number of fibroids)
Risk for IUFD in setting of large fibroid + fetal growth restriction
Obstetric management in patients with fibroidsMyomectomy DURING pregnancy
Generally not recommendedRisks of bleeding, preterm delivery/prematurity
Reserved for severe cases of uterine fibroids in pregnancy
Obstetric management in patients with fibroidsMyomectomy at time of cesarean delivery
Generally not performed unless absolutely necessary: to facilitate closure of hysterotomy
to facilitate delivery of the infant
Increased risk of hemorrhage requiring transfusion, uterine artery ligation/embolization or hysterectomy
Obstetric management in patients with fibroidsMyomectomy at time of cesarean delivery
Preoperative planning should include:Ultrasound mapping of fibroid in relationship to placenta and fetal position
Blood product availability
Appropriate back up should complications arise
Experienced GYN surgeon/Interventional Radiology
Obstetric management in patients with fibroids
In the rare case of a degenerating fibroid…
Diagnosis with ultrasound to correlate pain with fibroid location
Rule out other potential diagnoses in your differential (e.g. preterm labor, appendicitis, pyelonephritis, torsion, etc.)
Short course of NSAID therapy may be reasonable (expert opinion) following
trial of acetaminophene.g. ibuprofen or indomethacin
Obstetric management in patients with fibroids
In the even RARER case of infected degenerating fibroid (pyomyoma)…
Characteristic symptoms include:FeversMODERATE leukocytosisLack of response to appropriate therapy
Most often associated with termination of pregnancy or around time of delivery
Treatment: IV antibiotics with myomectomy or hysterectomy
Timing and mode of delivery in patients with prior myomectomy
Uterine rupture is primary concern!
Helpful information to guide decision for timing/mode of delivery:Operative report
Type/extent of uterine incision
Size and number of fibroids removed
Endometrial cavity entry (Yes or No)
WILLIAMSON, ET AL 2014. LO, ET AL. 2014
Mode of delivery in patients with prior myomectomy
If endometrial cavity was NOT entered at time of myomectomy
Trial of labor may be consideredCounseling similar to patients with prior LTCS
No special monitoring required in labor if history of pedunculated fibroid removal without involvement of the myometrium
WILLIAMSON, ET AL 2014. LO, ET AL. 2014
Mode of delivery in patients with prior myomectomy
If uterine cavity was entered or nearly entered at the time of myomectomy, a pre-labor scheduled cesarean delivery should be
undertaken
Uterine rupture in labor risks estimated from prior classical cesarean delivery data
Risk for uterine rupture 4%-9% for women with prior classical cesarean
ACOG Practice Bulletin #115 (VBAC)
WILLIAMSON, ET AL 2014. LO, ET AL. 2014
Timing of delivery in patients s/p myomectomy
SMFM Clinical Practice Guidelines. Prior non-lower segment uterine scar: when to plan cesarean delivery Society of Maternal Fetal Medicine with the assistance of
Cynthia Gyamfi-Bannerman, MD, published in Contemporary OB/GYN / dec 2013
WILLIAMSON, ET AL 2014. LO, ET AL. 2014